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STATE OF GEORGIA
                                                            APPLICATION FOR EMPLOYMENT
                                              Georgia Department of Defense version
                                            An Equal Opportunity Em ployer and Drug-Free W ork place

                      ANNOUNCEMENT JOB TITLE                                                                         ANNOUNCEMENT NUMBER



 PERSONAL INFORMATION:
  Last Name                                                                                            First Name                                              Middle Initials

  Street or Mailing Address                                                                                                                                    Apartment No.

  City                                                                                                 State     Zip Code                    County

  Contact Phone Numbers (s)                                                                            Email address
  Cell:                                       Home:

  EMPLOYMENT ELIGIBILITY:                         To be employed by the State of Georgia and the Georgia Department of Defense, you must meet certain
  State and Federal employment eligibility requirements. These include (but are not limited to) United States citizenship or authorization to work in this
  country, positive rehire status if previously employed by the State, and no felony convictions (for some jobs). Please answer the following questions.
  1. Are you a United States citizen?       2. Are you an alien authorized to work in          3. Have you ever been dismissed from any          4. Have you ever been convicted
                                                        the United States?                         State of Georgia government position?                   of a felony?
              YES           NO                      N/A           YES           NO                                  YES         NO                             YES          NO
                                                                                                      If YES, attach an explanation.             If YES, attach an explanation.


  EDUCATION:
  High School Graduate or         Vocational/Business School:                                        No. of      Field of Study:                           Completed: Yes        No
     Equivalent (GED)?                                                                               Months:                                               Date:
       Yes       No                                                                                                                                        (Mo/Yr)

                                                                                                                                                            TYPE OF           DATE
                                                                                      CREDIT
               PLEASE LIST EXACT COLLEGE HOURS :                                                                                                            DEGREE           DEGREE
                                                                                     RECEIVED                  FIELD/AREA OF CONCENTRATION
                                                                                                                                                                            COMPLETED
         COLLEGES/UNIVERSITIES              CITY and STATE           DATES           Qtr       Sem                                                         (BA/BS/
                                                                                     Hrs       Hrs          Major         Hrs        Minor           Hrs   MA/PhD)            (Mo./Yr.)
                                                                   ATTENDED




  OTHER LANGUAGES SPOKEN:                                                                                                                                  Sign Language

                                  Type of License/Certificate                                             License/Certificate           Expiration                   Specialization/
                                                                                                               Number                   (Mo./Yr.)                    Endorsements

  Current Valid Commercial Driver’s License (CDL): Class (Check One):      A     B         C

  Teacher Certified in Georgia: Type of Certificate Held:

  Other Professional License/Certificate:



  CERTIFICATION: Read carefully before signing and dating. Incomplete and/or unsigned applications will
  not be processed. I certify that all information on this application is correct. I authorize any agent or employee of the
  State to verify this information and to release it to anyone who may consider me for appointment. I understand that
  intentionally providing false information on this form or attachments is a violation of state law. I also understand that
  applications submitted electronically, via e-mail or similar media, are not valid unless I enter my name in the
  signature field below and such action shall constitute an electronic signature. I further certify that either: 1) I
  have not been convicted of a drug-related criminal offense; or 2) if I have been convicted of a drug-related criminal
  offense, it has been more than three (3) months since my first conviction, or more than five (5) years since a second or
  subsequent conviction (O.C.G.A. 45-23 et. Seq.).

  Signature:                                                                                                                                      Date:

GA DOD State Personnel Office                                                        Page 1                                                                   August 2011 version
Applicant Name:


  WORK HISTORY – ALL RELEVANT EXPERIENCE AND COMPLETE WORK HISTORY FOR THE PAST TEN YEARS:
  Complete ALL fields. Include military and volunteer experience; explain any GAPS in employment. If you worked for the same employer
  but held different jobs, describe each separately. Describe in detail the specific duties beginning with your primary duties. If you need
  more space, print additional work history page(s) and attach to the application. Include additional documents as requested, such as the
  DD214 member 4 copy. A resume may be attached but will not substitute for a completed application.

                  FAILURE TO GIVE COMPLETE AND DETAILED INFORMATION REGARDING EACH JOB HELD MAY RESULT IN
                                   YOUR DISQUALIFICATION FROM EMPLOYMENT CONSIDERATION.

  Current or Last Employer:                                                    Your Job Title:

  Address                                                                      From (mo/yr)              To (mo/yr)       Hours per Week:

  City                                          State    Zip Code              Check all that apply:                      Annual Salary
                                                                                 Volunteer           Intern   Paid
  Your Supervisor’s Name and Title                                                May We Contact Employer?            Your Supervisor’s Phone Number
                                                                                          YES        NO                 (     )
  Reason for Leaving                                                           # and types of employees you supervised:

  Describe in detail your job duties.   (Attach additional pages or continue on back if necessary.)




   Employer:                                                              Your Job Title:

   Address                                                                From (mo/yr)            To (mo/yr)          Hours per Week:

   City                                    State    Zip Code              Check all that apply:                       Annual Salary
                                                                            Volunteer           Intern   Paid
   Your Supervisor’s Name and Title                                          May We Contact Employer?               Your Supervisor’s Phone Number
                                                                                      YES       NO                 (      )
   Reason for Leaving                                                     # and types of employees you supervised:

   Describe in detail your job duties. (Attach additional pages or continue on back if necessary.)




   Employer:                                                              Your Job Title:

   Address                                                                From (mo/yr)               To (mo/yr)       Hours per Week:

   City                                    State    Zip Code              Check all that apply:                       Annual Salary
                                                                            Volunteer           Intern   Paid
   Your Supervisor’s Name and Title                                          May We Contact Employer?               Your Supervisor’s Phone Number
                                                                                      YES       NO                 (      )
   Reason for Leaving                                                     # and types of employees you supervised:

   Describe in detail your job duties. (Attach additional pages or continue on back if necessary.)




GADOD State Personnel Office                                              Page 2                                                   August 2011 version
Applicant Name:


   CONTINUED WORK HISTORY
   Employer:                                                             Your Job Title:

   Address                                                               From (mo/yr)                To (mo/yr)       Hours per Week:

   City                                    State    Zip Code             Check all that apply:                      Annual Salary
                                                                           Volunteer           Intern   Paid
   Your Supervisor’s Name and Title                                         May We Contact Employer?              Your Supervisor’s Phone Number
                                                                                     YES       NO                 (      )
   Reason for Leaving                                                    # and types of employees you supervised:

   Describe in detail your job duties. (Attach additional pages or continue on back if necessary.)




   Employer:                                                            Your Job Title:

   Address                                                              From (mo/yr)             To (mo/yr)          Hours per Week:

   City                                   State    Zip Code             Check all that apply:                       Annual Salary
                                                                          Volunteer           Intern   Paid
   Your Supervisor’s Name and Title                                        May We Contact Employer?               Your Supervisor’s Phone Number
                                                                                    YES       NO                 (      )
   Reason for Leaving                                                   # and types of employees you supervised:

   Describe in detail your job duties. (Attach additional pages or continue on back if necessary.)




                                    *** Attach additional w ork history pages if needed ***



   MILITARY SERVICE NOT LISTED ABOVE: Have you ever served in the United States Military?
                                                                   Yes (please com plete below )                  No (skip this section )

   Branch                              From                     To                         Type of Discharge
                                       (MM/DD/YYYY)             (MM/DD/YYYY)               ** if not honorable – please explain




GADOD State Personnel Office                                             Page 3                                                   August 2011 version
Applicant Name:


  EQUAL EMPLOYMENT OPPORTUNITY INFORMATION

  The information you give in this section is optional. It is used by the Georgia Department of Defense to comply with
  Federal guidelines for monitoring the equal employment opportunity efforts of the State of Georgia.

  Date:                                                             Announcement Number:



                               Ethnic Background (Check One):                               Gender             Birth Date
         American Indian                          White, not of Hispanic origin            (Check One):    MO        DAY        YR


         Hispanic                                 Black, not of Hispanic origin                Male

         Asian/Pacific Islander                   Multi-racial                                 Female     Birth Date - Required for
                                                                                                          some law enforcement
                                                                                                          jobs.



  For Agency Use




GADOD State Personnel Office                                     Page 4                                   August 2011 version

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  • 1. STATE OF GEORGIA APPLICATION FOR EMPLOYMENT Georgia Department of Defense version An Equal Opportunity Em ployer and Drug-Free W ork place ANNOUNCEMENT JOB TITLE ANNOUNCEMENT NUMBER PERSONAL INFORMATION: Last Name First Name Middle Initials Street or Mailing Address Apartment No. City State Zip Code County Contact Phone Numbers (s) Email address Cell: Home: EMPLOYMENT ELIGIBILITY: To be employed by the State of Georgia and the Georgia Department of Defense, you must meet certain State and Federal employment eligibility requirements. These include (but are not limited to) United States citizenship or authorization to work in this country, positive rehire status if previously employed by the State, and no felony convictions (for some jobs). Please answer the following questions. 1. Are you a United States citizen? 2. Are you an alien authorized to work in 3. Have you ever been dismissed from any 4. Have you ever been convicted the United States? State of Georgia government position? of a felony? YES NO N/A YES NO YES NO YES NO If YES, attach an explanation. If YES, attach an explanation. EDUCATION: High School Graduate or Vocational/Business School: No. of Field of Study: Completed: Yes No Equivalent (GED)? Months: Date: Yes No (Mo/Yr) TYPE OF DATE CREDIT PLEASE LIST EXACT COLLEGE HOURS : DEGREE DEGREE RECEIVED FIELD/AREA OF CONCENTRATION COMPLETED COLLEGES/UNIVERSITIES CITY and STATE DATES Qtr Sem (BA/BS/ Hrs Hrs Major Hrs Minor Hrs MA/PhD) (Mo./Yr.) ATTENDED OTHER LANGUAGES SPOKEN: Sign Language Type of License/Certificate License/Certificate Expiration Specialization/ Number (Mo./Yr.) Endorsements Current Valid Commercial Driver’s License (CDL): Class (Check One): A B C Teacher Certified in Georgia: Type of Certificate Held: Other Professional License/Certificate: CERTIFICATION: Read carefully before signing and dating. Incomplete and/or unsigned applications will not be processed. I certify that all information on this application is correct. I authorize any agent or employee of the State to verify this information and to release it to anyone who may consider me for appointment. I understand that intentionally providing false information on this form or attachments is a violation of state law. I also understand that applications submitted electronically, via e-mail or similar media, are not valid unless I enter my name in the signature field below and such action shall constitute an electronic signature. I further certify that either: 1) I have not been convicted of a drug-related criminal offense; or 2) if I have been convicted of a drug-related criminal offense, it has been more than three (3) months since my first conviction, or more than five (5) years since a second or subsequent conviction (O.C.G.A. 45-23 et. Seq.). Signature: Date: GA DOD State Personnel Office Page 1 August 2011 version
  • 2. Applicant Name: WORK HISTORY – ALL RELEVANT EXPERIENCE AND COMPLETE WORK HISTORY FOR THE PAST TEN YEARS: Complete ALL fields. Include military and volunteer experience; explain any GAPS in employment. If you worked for the same employer but held different jobs, describe each separately. Describe in detail the specific duties beginning with your primary duties. If you need more space, print additional work history page(s) and attach to the application. Include additional documents as requested, such as the DD214 member 4 copy. A resume may be attached but will not substitute for a completed application. FAILURE TO GIVE COMPLETE AND DETAILED INFORMATION REGARDING EACH JOB HELD MAY RESULT IN YOUR DISQUALIFICATION FROM EMPLOYMENT CONSIDERATION. Current or Last Employer: Your Job Title: Address From (mo/yr) To (mo/yr) Hours per Week: City State Zip Code Check all that apply: Annual Salary Volunteer Intern Paid Your Supervisor’s Name and Title May We Contact Employer? Your Supervisor’s Phone Number YES NO ( ) Reason for Leaving # and types of employees you supervised: Describe in detail your job duties. (Attach additional pages or continue on back if necessary.) Employer: Your Job Title: Address From (mo/yr) To (mo/yr) Hours per Week: City State Zip Code Check all that apply: Annual Salary Volunteer Intern Paid Your Supervisor’s Name and Title May We Contact Employer? Your Supervisor’s Phone Number YES NO ( ) Reason for Leaving # and types of employees you supervised: Describe in detail your job duties. (Attach additional pages or continue on back if necessary.) Employer: Your Job Title: Address From (mo/yr) To (mo/yr) Hours per Week: City State Zip Code Check all that apply: Annual Salary Volunteer Intern Paid Your Supervisor’s Name and Title May We Contact Employer? Your Supervisor’s Phone Number YES NO ( ) Reason for Leaving # and types of employees you supervised: Describe in detail your job duties. (Attach additional pages or continue on back if necessary.) GADOD State Personnel Office Page 2 August 2011 version
  • 3. Applicant Name: CONTINUED WORK HISTORY Employer: Your Job Title: Address From (mo/yr) To (mo/yr) Hours per Week: City State Zip Code Check all that apply: Annual Salary Volunteer Intern Paid Your Supervisor’s Name and Title May We Contact Employer? Your Supervisor’s Phone Number YES NO ( ) Reason for Leaving # and types of employees you supervised: Describe in detail your job duties. (Attach additional pages or continue on back if necessary.) Employer: Your Job Title: Address From (mo/yr) To (mo/yr) Hours per Week: City State Zip Code Check all that apply: Annual Salary Volunteer Intern Paid Your Supervisor’s Name and Title May We Contact Employer? Your Supervisor’s Phone Number YES NO ( ) Reason for Leaving # and types of employees you supervised: Describe in detail your job duties. (Attach additional pages or continue on back if necessary.) *** Attach additional w ork history pages if needed *** MILITARY SERVICE NOT LISTED ABOVE: Have you ever served in the United States Military? Yes (please com plete below ) No (skip this section ) Branch From To Type of Discharge (MM/DD/YYYY) (MM/DD/YYYY) ** if not honorable – please explain GADOD State Personnel Office Page 3 August 2011 version
  • 4. Applicant Name: EQUAL EMPLOYMENT OPPORTUNITY INFORMATION The information you give in this section is optional. It is used by the Georgia Department of Defense to comply with Federal guidelines for monitoring the equal employment opportunity efforts of the State of Georgia. Date: Announcement Number: Ethnic Background (Check One): Gender Birth Date American Indian White, not of Hispanic origin (Check One): MO DAY YR Hispanic Black, not of Hispanic origin Male Asian/Pacific Islander Multi-racial Female Birth Date - Required for some law enforcement jobs. For Agency Use GADOD State Personnel Office Page 4 August 2011 version